Private Contract Sample for Providers that Opt Out of Medicare

If you have opted out of Medicare, you are required to have a private contract with the beneficiary, in addition to filing for an affidavit with all Medicare contractors. The affidavit must be filed within 10 days of entering into the first private contract with a Medicare beneficiary. A sample contract (PDF) is available to ensure you are meeting the requirements as an Opt-Out Provider. 

Please also refer to the article "Providers Opting Out of Medicare: Private Contracting" on our website for additional requirements.